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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609007
Report Date: 05/12/2022
Date Signed: 05/12/2022 04:57:59 PM


Document Has Been Signed on 05/12/2022 04:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:GLENDALE GARDEN CARE HOMEFACILITY NUMBER:
197609007
ADMINISTRATOR:DEANON, IRENEFACILITY TYPE:
740
ADDRESS:405 CHESTER STREETTELEPHONE:
(818) 640-2912
CITY:GLENDALESTATE: CAZIP CODE:
91203
CAPACITY:6CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Irene DeanonTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with Administrator Irene Deanon and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff files. The facility cares for elderly residents and is allowed to have 6 hospice residents. There is currently no resident on hospice.
Facility is licensed to serve 6 residents over the age of 60, 6 non-ambulatory of which 6 may be bedridden and has a hospice waiver for 6. Facility is a one story building located in residential area. Facility serves dementia residents and has auditory devices in exit doors. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located at the entrance of facility. Sign in sheet, hand sanitizer, gloves and masks are available. Staff conducted a routine symptom screening of LPA at the time of entrance and have a sign-in policy as required per COVID-19 procedures. All staff were observed to be wearing mask during this visit.
LPA observed that the facility does not have a swimming pool or other bodies of water. All indoor and outdoor passageways are free of obstruction. Resident bedrooms were inspected. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. All bathrooms have the required grabs bars and non-skid mat. The hot water was between 105.4 - 106.2 degrees which is within the required 105 - 120 degrees. Cleaning supplies locked in the laundry area and under kitchen sink are inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the living room, dining room, small TV room and patio area. These areas are clean and have the required furniture. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations.

Continue 809C



SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GLENDALE GARDEN CARE HOME
FACILITY NUMBER: 197609007
VISIT DATE: 05/12/2022
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LPA observed two fire extinguishers are fully charged. Smoke/carbon monoxide detectors were tested and in working condition. LPA reviewed residents and staff records. Residents' records were found to be complete and current. Staff files were reviewed, and documentation noted that facility staff maintain a criminal record clearance and associated to the facility. LPA reviewed residents' medications. Medications are documented properly and stored appropriately.

Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview was conducted with Administrator and a copy of this report was provided.


SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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